THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY"

Transcription

1 FLEXI PLUS FIVE APPLICATION NOT-FOR-PROFIT ORGANIZATION DIRECTORS AND OFFICERS LIABILITY INSURANCE EMPLOYMENT PRACTICES LIABILITY INSURANCE FIDUCIARY LIABILITY INSURANCE WORKPLACE VIOLENCE COVERAGE INTERNET LIABILITY INSURANCE THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY Instructions: Whenever used in this Application the term Applicant shall mean the Parent Organization and its whollyowned/controlled subsidiaries. The Applicant is required to complete Sections 1, 2, and 7. The Applicant should complete other applicable Section(s) for which coverage is desired. (See chart below) Check Coverage Desired Section Requested Limit Requested Retention General Information 1 N/A N/A Directors & Officers 2 $ $ Employment Practices 3 $ $ Fiduciary Liability 4 $ $ Workplace Violence 5 $ $ Internet Liability 6 $ $ General Summary 7 N/A N/A SECTION 1 GENERAL INFORMATION (All Applicants must complete this section) 1. Name of Parent Organization: 2. Address: Telephone: ( ) Internet Address: www. 3. Date Established: State of Incorporation: 4. Standard Industrial Classification (SIC) #: 4a. Federal Employer Identification (FEIN) #: 5. Please describe the nature of the Applicant s operations: 6. Does the Applicant have a tax-exempt status under the U.S. Internal Revenue Code? Yes No If no, provide an explanation. 7. The Officer of the Applicant designated to receive any and all notices from the Underwriter or their authorized representative concerning this insurance is: Name Title Address PIIC-NPD-NEW APP (09/06) Page 1 of 8

2 8. Number of Members: Number of Chapters: Please attach details for all YES answers to questions Does the Applicant publish any magazines, periodicals or newsletters? Yes No 10. Is the Applicant involved in product research, product development, testing and/or certification? Yes No 11. Does the Applicant set standards for the qualification and performance and/or certify its members? Yes No 12. Does the Applicant engage in any disciplinary actions as a result of peer review activities? Yes No 13. Does the Applicant administer or sponsor any insurance programs for its members? Yes No FINANCIAL INFORMATION CURRENT FISCAL YEAR PREVIOUS FISCAL YEAR TOTAL ASSETS: $ $ NET ASSETS / FUND BALANCE: $ $ ANNUAL REVENUE: $ $ NET REVENUE $ $ Please attach the most recent annual financial audit or 990 form. SECTION 2 DIRECTORS AND OFFICERS (All Applicants must complete this section) 1. Directors and Officers Liability Insurance has been continuously in force since: 2. Provide a list of all direct and indirect subsidiaries or any other entity or organization the Applicant controls: Percent the Applicant DateCreated/ For Profit / Name/Type of Business Owns/Controls Acquired Non-Profit Example: ABC Foundation, Inc/ Charitable Children s Foundation 100% 01/01/2000 Non-Profit Additional entities listed by attachment 3. Has the Applicant or any person proposed for coverage herein been the subject of, or involved in, any of the following in the past five (5) years? If yes, please attach details. Anti-trust, copyright or patent litigation? Yes No Any disciplinary action by any regulatory agency or association? Yes No Any action where a license was revoked or suspended? Yes No Any administrative proceeding charging violation of a federal or state law or regulation? Yes No Any other criminal actions? Yes No It is agreed that with respect to Question #3, if such circumstances exist, any claim arising from such circumstances are excluded from the proposed insurance. PIIC-NPD-NEW APP (09/06) Page 2 of 8

3 4. In the past twenty-four (24) months or the next twelve (12) months, has the Applicant been, or anticipate being involved in any of the following? Mergers, acquisitions or consolidation with another entity? If yes, please attach details. Yes No Changes in the board of directors or senior management (other than death or retirement)? Yes No If yes, please attach details. 5. Does the Applicant direct or request any individual to serve as director, officer, governor or trustee of any other entity? Yes No If yes, please attach details. SECTION 3 EMPLOYMENT PRACTICES (Complete this section only if Employment Practices Liability coverage is desired.) 1. Employment Practices Liability Insurance has been continuously in force since: 2. Please provide the following employee count information: U.S. based employees/volunteers: Currently One Year Ago Two Years Ago Full Time employees: Part Time employees: Temporary employees: Volunteers: Non U.S. based employees/volunteers: TOTAL SUM OF ABOVE 3. How many employees have been terminated or demoted in the past twelve (12) months? Voluntary: Involuntary: Laid Off: Demoted: 4. Is any reduction of employees or change of status anticipated in the next year? Voluntary: Involuntary: Layoffs: Demotions: 5. Does the Applicant have an employment handbook? Yes No 6. Does the Applicant use an employment application for every potential employee? Yes No 7. Does the Applicant have an At Will provision in the employment application or handbook? Yes No 8. Has the Applicant implemented an anti-sexual harassment policy? Yes No 9. Has the Applicant implemented an anti-discrimination policy? Yes No 10. Does the Applicant use outside employment counsel for employment advise? Yes No SECTION 4 FIDUCIARY LIABILITY (Complete this section only if Fiduciary liability coverage is desired.) 1. Fiduciary Liability Insurance has been continuously in force since: 2. List all plans for which coverage is requested (use attachment if necessary): Year Assets/ Plan Name Established Contributions Type* Participants Administrator Example: The ABC Children Corp 401K Plan 2000 $1,000, self a) b) c) d) * 1=Employee Welfare Benefit Plan (as defined by ERISA), 2= Defined Contribution Plan (as defined by ERISA), 3= Defined Benefit Plan (as defined by ERISA), 4=Other. If Type is 3 or 4 a Fiduciary Liability Supplemental Application must be completed. Please attach a separate page or use the additional information page provided at the end of the application. PIIC-NPD-NEW APP (09/06) Page 3 of 8

4 3. Does any plan(s) employ the investment, trustee, actuarial, legal, administrative, custodial or benefits consulting services of any outside provider? Yes No If yes, please attach details. 4. Has termination been requested or contemplated for any plan? Yes No 5. Has any amendment to any plan been made or contemplated within the past two (2) years, or is any amendment now contemplated, which has resulted or might result in any reduction of benefits including, but not limited to, an increase in participants portion of cost? Yes No If yes, please attach details. If there has been any amendment(s), please attach copies. 6. Has any plan been spun-off (sold), transferred or terminated? Yes No If yes, please attach details. 7. Are there or have there been within the last three (3) years any known or alleged violations of ERISA or any similar statutory or common law (including applicable amendments, rules and regulations) of the United States, Canada or any state or other jurisdiction to which a plan is subject? Yes No If yes, please attach details. 8. Does the Applicant have any information to suggest or indicate that any of the plans it sponsors may be under governmental or regulatory investigation with regard to the applicable plan s funding, administration or investment strategies? Yes No If yes, please attach details. 9. Is Form 5500 filed on an annual basis for each plan? Yes No If yes, provide a copy of the most recent 5500; If no, please attach details. SECTION 5 WORKPLACE VIOLENCE (Complete this section only if Workplace Violence coverage is desired.) Please attach a copy of your employee and customer complaint/grievance procedures. 1. Workplace Violence Insurance has been continuously in force since: 2. The Applicant s total number of work locations: 3. The Applicant s total number of employees: 4. Does the Applicant: have an employee assistance program? Yes No have a progressive disciplinary policy? Yes No have an employee complaint/grievance resolution procedure? Yes No have a written policy on workplace violence that is circulated to all employees? Yes No train employees to recognize, report, and respond to potentially hostile situations? Yes No have a process for performing background checks for all potential employees? Yes No 5. In the past twelve (12) months, has the Applicant been involved with any layoffs, staff reductions, or facility closings? Yes No If yes, please attach details. 6. In the next twelve (12) months, does the Applicant contemplate any layoffs, staff reductions, or facility closings? Yes No If yes, please attach details. 7. Has the Applicant or any person proposed for coverage herein been the subject of, or involved in, any incidents of workplace violence in the last five years? Yes No If yes, please attach details. PIIC-NPD-NEW APP (09/06) Page 4 of 8

5 SECTION 6 INTERNET LIABILITY (Complete this section only if Internet Liability coverage is desired.) 1. Internet Liability Insurance has been continuously in force since: 2. Please identify the internet site(s) for which coverage is sought, the date each site first went on-line, and (if known) the average number of page views per month: Internet site address Date on-line Average page views per month 3. Does the Applicant conduct transactions (e-commerce) on the site or is the site informative only? Transactional / E-commerce (Please complete questions 4, 5 & 6) Informational Only (Please go to question 6) Both (Please complete questions 4, 5,& 6) 4. The Applicant s projected annual gross revenues from the internet site: $ 5. Please describe the type and purpose of the transactions performed on the site: 6. What percentage of monthly page views on the Applicant s internet site originates outside the U.S. and Canada? % SECTION 7 GENERAL SUMMARY (All Applicants must complete this section.) 1. Has the Applicant given written notice under the provisions of any prior policies providing similar insurance or claims, or of specific facts or circumstances which might give rise to a claim being made against any person or entity applying for this insurance? Yes No If yes, complete a Claim Supplemental for each incident. 2. No person applying for this coverage is aware of any facts or circumstances which he or she has reason to suppose might give rise to a future claim that would fall within the scope of any of the proposed coverages for which the Applicant has applied, except: None or as noted below: 3. Current Coverage COVERAGES Insurance Company Limit of Liability Deductible Policy Effective Dates Premium D&O $ $ $ EPLI $ $ $ Fiduciary $ $ $ Workplace $ $ $ Violence Internet Liability $ $ $ General Liability $ $ $ Professional Liability $ $ $ PIIC-NPD-NEW APP (09/06) Page 5 of 8

6 4. With respect to the above coverage, has any Underwriter refused, canceled or non-renewed coverage? (Not Applicable in Missouri) Yes No If yes, provide details. Material Change If there is any material change to the answers of this Application s questions prior to the policy inception date, the Applicant must notify the Underwriter in writing. Any outstanding quotation may be modified or withdrawn. False Information WARNING: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME. NOTICE TO MINNESOTA AND OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD, WHICH IS A CRIME. NOTICE TO OKLAHOMA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKE ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE, INSURANCE COMPANY, OR SELF-INSURED PROGRAM, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. PIIC-NPD-NEW APP (09/06) Page 6 of 8

7 NOTICE TO DISTRICT OF COLUMBIA, MAINE AND VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, OR A DENIAL OF INSURANCE BENEFITS. NOTICE TO NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD. NOTICE TO OREGON AND TEXAS APPLICANTS: ANY PERSON WHO MAKES AN INTENTIONAL MISSTATEMENT THAT IS MATERIAL TO THE RISK MAY BE FOUND GUILTY OF INSURANCE FRAUD BY A COURT OF LAW. NOTICE TO TENNESSEE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. Signature The Undersigned warrants that to the best of his/her knowledge and belief the statements set forth herein are true. The Undersigned further declares that any occurrence or event that takes place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Underwriter. The Underwriter may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The Underwriter is hereby authorized to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The signing of this Application does not bind the Undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is agreed that this Application shall be the basis of the contract should a policy be issued. This Application will be attached and become a part of the policy. Name (Please Print) Signature Title (MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN OR EXECUTIVE DIRECTOR) Date The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons. Produced By: (Section to be completed by Agent/Broker) Agent: Agency: Agency Taxpayer ID or SS No.: Agent License No: Address (Street, City, State, Zip) : PIIC-NPD-NEW APP (09/06) Page 7 of 8

8 ADDITIONAL INFORMATION This page may be used to provide additional information to any question on this application. Please identify the question number to which you are referring. Signature Date PIIC-NPD-NEW APP (09/06) Page 8 of 8

Instructions Whenever used in this Application the term Applicant shall mean the Parent Organization and its whollyowned/controlled

Instructions Whenever used in this Application the term Applicant shall mean the Parent Organization and its whollyowned/controlled Philadelphia Insurance Companies One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 610.617.7900 Fax: 610.617.7940 FLEXI PLUS FIVE APPLICATION NOT-FOR-PROFIT ORGANIZATION DIRECTORS AND OFFICERS

More information

Philadelphia Insurance Companies One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004

Philadelphia Insurance Companies One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 Philadelphia Insurance Companies One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 APPLICATION FOR: PRIVATE COMPANY PROTECTION PLUS DIRECTORS AND OFFICERS & PRIVATE COMPANY LIABILITY INSURANCE

More information

NON-PROFIT DIRECTORS AND OFFICERS LIABILITY INSURANCE THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY

NON-PROFIT DIRECTORS AND OFFICERS LIABILITY INSURANCE THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY BOLLINGER INC. 101 JFK PARKWAY SHORT HILLS, NJ 07078 NON-PROFIT DIRECTORS AND OFFICERS LIABILITY INSURANCE THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY PART I GENERAL

More information

Executive Protection Portfolio SM Fiduciary Liability Coverage Application

Executive Protection Portfolio SM Fiduciary Liability Coverage Application BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK INDEMNITY INC. (THE COMPANY ) NOTICE: THE FIDUCIARY LIABILITY COVERAGE SECTION OF THIS POLICY PROVIDES CLAIMS MADE COVERAGE,

More information

APPLICATION FOR DIRECTORS AND OFFICERS LIABILITY INSURANCE POLICY INCLUDING EMPLOYMENT PRACTICES LIABILITY COVERAGE

APPLICATION FOR DIRECTORS AND OFFICERS LIABILITY INSURANCE POLICY INCLUDING EMPLOYMENT PRACTICES LIABILITY COVERAGE APPLICATION FOR DIRECTORS AND OFFICERS LIABILITY INSURANCE POLICY INCLUDING EMPLOYMENT PRACTICES LIABILITY COVERAGE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES, SUBJECT TO ITS TERMS, ONLY

More information

BY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY )

BY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY ) BY COMPLETING THIS NEW BUSINESS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE COMPANY ) NOTICE: PLEASE ANSWER ALL OF THE FOLLOWING INQUIRIES.

More information

APPLICATION FOR EMPLOYEE BENEFIT PLAN FIDUCIARY INSURANCE

APPLICATION FOR EMPLOYEE BENEFIT PLAN FIDUCIARY INSURANCE APPLICATION FOR EMPLOYEE BENEFIT PLAN FIDUCIARY INSURANCE NOTICE: THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THE POLICY FOR WHICH THIS APPLICATION IS MADE IS LIMITED TO LIABILITY FOR

More information

BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH THE INSURANCE COMPANY INDICATED ABOVE (THE INSURER ).

BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH THE INSURANCE COMPANY INDICATED ABOVE (THE INSURER ). Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Markel Insurance Company Associated International Insurance Company

More information

APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE

APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE Monroe Insurance Brokerage, Inc. Home Office M o n t e r e y, C a l i f o r n i a 9 3 9 4 0 APPLICATION FOR BROAD FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH THIS APPLICATION

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION

EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION THIS IS AN APPLICATION FOR A POLICY THAT IS WRITTEN ON A CLAIMS-MADE BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE

More information

Application For Business and Management (BAM) Indemnity Insurance

Application For Business and Management (BAM) Indemnity Insurance Application For Business and Management (BAM) Indemnity Insurance NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE, SUBJECT TO ITS TERMS, APPLIES ONLY TO ANY CLAIM OR LOSS DISCOVERED (AS APPLICABLE IN

More information

Nonprofit Directors & Officers Liability Insurance

Nonprofit Directors & Officers Liability Insurance Nonprofit Directors & Officers Liability Insurance CLAIMS MADE WARNING FOR APPLICATION THIS PROPOSAL FORM IS FOR A CLAIMS MADE AND REPORTED POLICY, RELATING TO CLAIMS MADE AGAINST THE INSUREDS DURING THE

More information

SAFETY NET SHORT FORM INTERNET LIABILITY INSURANCE APPLICATION

SAFETY NET SHORT FORM INTERNET LIABILITY INSURANCE APPLICATION Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey 07059 Executive Risk Indemnity Inc. 2711 Centerville Road Suite 400, Wilmington, Delaware 19808 SAFETY NET SHORT FORM INTERNET

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION

EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION THIS IS AN APPLICATION FOR A POLICY THAT IS WRITTEN ON A CLAIMS-MADE BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE

More information

PENSION AND WELFARE FUND FIDUCIARY DISHONESTY POLICY APPLICATION

PENSION AND WELFARE FUND FIDUCIARY DISHONESTY POLICY APPLICATION BY COMPLETING THIS THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE: READ THE ENTIRE CAREFULLY BEFORE SIGNING. INSTRUCTIONS: 1. Whenever used in this Pension

More information

APPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE

APPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE Executive Risk Management Associates 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED

More information

RENEWAL APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE

RENEWAL APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE Executive Risk Indemnity Home Office Wilmington, Delaware 19808 Administrative Offices/Mailing 82 Hopmeadow Simsbury, Connecticut RENEWAL APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE NOTICE:

More information

Application For Business and Management (BAM) Indemnity Insurance Non-Profit Organizations

Application For Business and Management (BAM) Indemnity Insurance Non-Profit Organizations Northwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com

More information

DIRECTORS AND OFFICERS LIABILITY-NOT FOR PROFIT ORGANIZATION APPLICATION

DIRECTORS AND OFFICERS LIABILITY-NOT FOR PROFIT ORGANIZATION APPLICATION DIRECTORS AND OFFICERS LIABILITY-NOT FOR PROFIT ORGANIZATION APPLICATION RSUI Indemnity Company Landmark American Insurance Company NOTICE: THIS IS A CLAIMS MADE AND REPORTED POLICY THAT APPLIES ONLY TO

More information

Application For ACE EXPRESS Non Profit Organization Management Indemnity Package

Application For ACE EXPRESS Non Profit Organization Management Indemnity Package Application For ACE EXPRESS n Profit Organization Management Indemnity Package NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE, SUBJECT TO ITS TERMS, APPLIES ONLY TO ANY CLAIM MADE AGAINST ANY OF THE

More information

AFFINITY PRO PORTFOLIO APPLICATION

AFFINITY PRO PORTFOLIO APPLICATION AFFINITY PRO PORTFOLIO APPLICATION TRADE ASSOCIATION PROFESSIONAL LIABILITY NOT-FOR-PROFIT ORGANIZATION DIRECTORS AND OFFICERS LIABILITY INSURANCE EMPLOYMENT PRACTICES LIABILITY INSURANCE FIDUCIARY LIABILITY

More information

Total Number Active Number Total Type Full Name of Plan of Plan of Plan Plan of Participants Participants Assets Plan*

Total Number Active Number Total Type Full Name of Plan of Plan of Plan Plan of Participants Participants Assets Plan* PLAZA INSURANCE COMPANY a member of the State Auto Group Application for Fiduciary Liability Coverage GENERAL INFORMATION Parent Company: Address: Website: State of Incorporation: Years of Operation: Type

More information

Executive Risk Indemnity Inc.

Executive Risk Indemnity Inc. Executive Risk Indemnity Inc. Home Office: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR MANAGEMENT LIABILITY INSURANCE FOR PROFESSIONAL FIRMS NOTICE: THE POLICY FOR WHICH APPLICATION

More information

BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK SPECIALTY INSURANCE COMPANY (THE UNDERWRITER )

BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK SPECIALTY INSURANCE COMPANY (THE UNDERWRITER ) BY COMPLETING THIS YOU ARE APPLYING FOR COVERAGE WITH EXECUTIVE RISK SPECIALTY INSURANCE COMPANY (THE UNDERWRITER ) NOTICE: THE LIMIT OF LIABILITY TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED AND MAY

More information

SAFETY NET INTERNET LIABILITY INSURANCE RENEWAL APPLICATION

SAFETY NET INTERNET LIABILITY INSURANCE RENEWAL APPLICATION Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey 07059 Executive Risk Indemnity Inc. 2711 Centerville Road Suite 400, Wilmington, Delaware 19808 SAFETY NET INTERNET LIABILITY

More information

MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION

MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION NOTICE: THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY, WHICH, SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO CLAIMS WHICH ARE BOTH FIRST MADE

More information

Admiral Insurance Company

Admiral Insurance Company Executive Liability Insurance Proposal Form for Employment Practices Liability CLAIMS MADE WARNING FOR APPLICATION: This Proposal Form is for a Claims Made and Reported Policy, relating to claims made

More information

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group)

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) EMPLOYMENT PRACTICES LIABLITY INSURANCE APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION

More information

RENEWAL Application for Business and Management (BAM) Indemnity Insurance

RENEWAL Application for Business and Management (BAM) Indemnity Insurance rthwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com

More information

RENEWAL Application for Business and Management (BAM) Indemnity Insurance

RENEWAL Application for Business and Management (BAM) Indemnity Insurance rthwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com

More information

BY COMPLETING THIS NEW BUSINESS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY )

BY COMPLETING THIS NEW BUSINESS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) .. BY COMPLETING THIS THE APPLICANT IS APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE COMPANY ) NOTICE: INSURING CLAUSE A OF THE POLICY PROVIDES CLAIMS MADE COVERAGE, WHICH APPLIES ONLY TO "CLAIMS"

More information

MULTIMEDIA SM LIABILITY Application for Advertising Agencies

MULTIMEDIA SM LIABILITY Application for Advertising Agencies BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH EXECUTIVE RISK INDEMNITY INC. ( Insurer ) NOTICE: THE LIMIT OF LIABILITY TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED AND MAY

More information

ERRORS & OMISSIONS INSURANCE APPLICATION

ERRORS & OMISSIONS INSURANCE APPLICATION ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: Indian Harbor Insurance Company 505 Eagleview Blvd. Suite 100 Dept: Regulatory Exton, PA 19341-1120 Telephone: 800-688-1840 THIS IS AN APPLICATION

More information

ERRORS & OMISSIONS RENEWAL APPLICATION

ERRORS & OMISSIONS RENEWAL APPLICATION ERRORS & OMISSIONS RENEWAL APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE

More information

TORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477

TORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477 TORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477 APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE TO ALL APPLICANTS:

More information

6. Does Applicant encrypt all sensitive and Personally Identifiable Information? Yes No If yes, give details:

6. Does Applicant encrypt all sensitive and Personally Identifiable Information? Yes No If yes, give details: Name of Insurance Company to which Application is made (herein called the Insurer ) CORPORATE IDENTITY PROTECTION NOTICE: AMOUNTS INCURRED FOR DEFENSE COSTS, ADMINISTRATIVE EXPENSES, NOTIFICATION COSTS,

More information

Hudson Insurance Company 100 William Street, New York, NY 10038

Hudson Insurance Company 100 William Street, New York, NY 10038 Hudson Insurance Company 100 William Street, New York, NY 10038 APPLICATION FOR DIRECTORS & OFFICERS INSURANCE POLICY COMPLETION OF THIS APPLICATION DOES NOT COMMIT OR BIND THE UNDERSIGNED TO PURCHASE

More information

PLAZA. Application for Not For Profit Individual and Organization Management Liability Insurance Including Employment Practices Liability Coverage

PLAZA. Application for Not For Profit Individual and Organization Management Liability Insurance Including Employment Practices Liability Coverage PLAZA INSURANCE COMPANY a member of the State Auto Group Application for Not For Profit Individual and Organization Management Liability Insurance Including Employment Practices Liability Coverage GENERAL

More information

IRONSHORE INSURANCE COMPANIES One State Street Plaza, 7 th Floor New York, New York 10004 Tel: 646-826-6600 Toll Free: 877-IRON411

IRONSHORE INSURANCE COMPANIES One State Street Plaza, 7 th Floor New York, New York 10004 Tel: 646-826-6600 Toll Free: 877-IRON411 IRONSHORE INSURANCE COMPANIES One State Street Plaza, 7 th Floor New York, New York 10004 Tel: 646-826-6600 Toll Free: 877-IRON411 Miscellaneous Professional Liability Insurance Application THE APPLICANT

More information

Miscellaneous Professional Liability Application

Miscellaneous Professional Liability Application Name of insurance company to which Application is made (the Insurer ) Miscellaneous Professional Liability Application NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS

More information

INSTRUCTIONS FOR COMPLETING THIS APPLICATION

INSTRUCTIONS FOR COMPLETING THIS APPLICATION MAIN FORM APPLICATION FOR PRIVATE COMPANY DIRECTORS AND OFFICERS AND CORPORATE LIABILITY INCLUDING EMPLOYMENT PRACTICES LIABILITY INSURANCE ( PRIVATE PLUS ) Name of Insurance Company to which this Application

More information

NON PROFIT MANAGEMENT LIABILITY APPLICATION

NON PROFIT MANAGEMENT LIABILITY APPLICATION NON PROFIT MANAGEMENT LIABILITY APPLICATION THIS APPLICATION IS FOR A CLAIMS MADE POLICY. "CLAIMS" MUST BE FIRST MADE AGAINST AN "INSURED PERSON" DURING THE "POLICY PERIOD" OR ANY APPLICABLE EXTENDED REPORTING

More information

Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group)

Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group) Homeland Insurance Company of New York Homeland Insurance Company of Delaware (Stock companies owned by the OneBeacon Insurance Group) NETWORK SECURITY AND PRIVACY LIABILITY RENEWAL APPLICATION PORTIONS

More information

APPLICATION FOR THE HARTFORD NON-PROFIT CHOICE SM ALL COVERAGE PARTS

APPLICATION FOR THE HARTFORD NON-PROFIT CHOICE SM ALL COVERAGE PARTS Name of Insurance Company to which application is made APPLICATION FOR THE HARTFORD NON-PROFIT CHOICE SM ALL COVERAGE PARTS NOTICE: THE LIABILITY COVERAGE PARTS SCHEDULED IN ITEM 5 OF THE DECLARATIONS

More information

APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY GENERAL INFORMATION

APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY GENERAL INFORMATION APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY Instructions for Completing This Application Please read carefully and fully answer all questions and submit all requested information

More information

APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE

APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE Executive Risk Indemnity Inc. Home Office Wilmington, Delaware 19805-1297 Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR ACCOUNTANTS PROFESSIONAL

More information

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group)

Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS

More information

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES ONLY TO CLAIMS FIRST MADE DURING THE POLICY PERIOD AND REPORTED TO THE COMPANY DURING THE

More information

APPLICATION FOR MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE FOR STANDARDS AND SPECIFICATIONS

APPLICATION FOR MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE FOR STANDARDS AND SPECIFICATIONS APPLICATION FOR MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE FOR STANDARDS AND SPECIFICATIONS SPONSORED BY: AMERICAN SOCIETY OF ASSOCIATION EXECUTIVES MEDIA/PROFESSIONAL INSURANCE a business unit of

More information

ERRORS & OMISSIONS INSURANCE APPLICATION

ERRORS & OMISSIONS INSURANCE APPLICATION ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE

More information

Employed Lawyers Professional Liability Application

Employed Lawyers Professional Liability Application Employed Lawyers Professional Liability Application THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED INSURANCE. NOTICE: THE LIMIT OF LIABILITY AVAILABE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED

More information

BEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION

BEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION BEAZLEY BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION NOTICE: INSURING AGREEMENTS I.A., I.C., I.D. AND I.F. OF THIS POLICY PROVIDE COVERAGE

More information

NON-PROFIT MANAGEMENT AND ORGANIZATION LIABILITY INSURANCE POLICY

NON-PROFIT MANAGEMENT AND ORGANIZATION LIABILITY INSURANCE POLICY NON-PROFIT MANAGEMENT AND ORGANIZATION LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE, SUBJECT TO ITS TERMS, APPLIES ONLY TO ANY CLAIM (AS DEFINED IN THE POLICY)

More information

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES ONLY TO CLAIMS FIRST MADE DURING THE POLICY PERIOD AND REPORTED TO THE COMPANY DURING THE

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION

EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION NOTICES: THE EMPLOYMENT PRACTICES LIABILITY COVERAGE PART/ENDORSEMENT PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR

More information

SmartPro Property Managers E&O Application

SmartPro Property Managers E&O Application NOTICE: THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED COVERAGE, WHICH APPLIES ONLY TO "CLAIMS" FIRST MADE AND REPORTED IN WRITING DURING THE "POLICY PERIOD," OR ANY EXTENDED REPORTING PERIOD. THE LIMIT

More information

NON-PROFIT ORGANIZATION MANAGEMENT LIABILITY INSURANCE POLICY APPLICATION

NON-PROFIT ORGANIZATION MANAGEMENT LIABILITY INSURANCE POLICY APPLICATION NON-PROFIT ORGANIZATION MANAGEMENT LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO ITS TERMS. THIS POLICY APPLIES

More information

OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application

OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application NOTICE: This is an application for a claims-made and reported policy. Subject to its terms, this policy

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION 610-668-7100 MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO

More information

LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION

LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY. SUBJECT TO ITS TERMS, THE POLICY APPLIES

More information

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE

APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES ONLY TO CLAIMS FIRST MADE DURING THE POLICY PERIOD AND REPORTED TO THE COMPANY DURING THE

More information

ARCH CANOPY POLICY FOR NONPROFIT ORGANIZATIONS SM APPLICATION

ARCH CANOPY POLICY FOR NONPROFIT ORGANIZATIONS SM APPLICATION ARCH CANOPY POLICY FOR NONPROFIT ORGANIZATIONS SM APPLICATION NOTICE: THE LIABILITY COVERAGE PARTS OF THIS POLICY PROVIDE CLAIMS MADE COVERAGE. EXCEPT AS OTHERWISE PROVIDED, SUCH COVERAGE APPLIES ONLY

More information

Eidyia Insurance Services

Eidyia Insurance Services Eidyia Insurance Services MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS. NOTICE: THE LIMIT OF LIABILITY AVAILABLE TO

More information

TORUS NATIONAL INSURANCE COMPANY MANAGEMENT LIABILITY APPLICATION FOR PRIVATE COMPANIES (NON-FINANCIAL INSTITUTIONS)

TORUS NATIONAL INSURANCE COMPANY MANAGEMENT LIABILITY APPLICATION FOR PRIVATE COMPANIES (NON-FINANCIAL INSTITUTIONS) TORUS NATIONAL INSURANCE COMPANY MANAGEMENT LIABILITY APPLICATION FOR PRIVATE COMPANIES (NON-FINANCIAL INSTITUTIONS) THIS APPLICATION APPLIES TO MANY COVERAGE PARTS. ACCORDINGLY, IT IS ONLY NECESSARY TO

More information

ACE Advantage. Employed Lawyers Professional Liability Application

ACE Advantage. Employed Lawyers Professional Liability Application ACE American Insurance Company Illinois Union Insurance Company Westchester Fire Insurance Company Westchester Surplus Lines Insurance Company ACE Advantage Employed Lawyers Professional Liability Application

More information

MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION

MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION THIS IS AN APPLICATION FOR CLAIMS-MADE AND REPORTED INSURANCE PROVIDED THROUGH HORIZON RISK INSURANCE, LLC. IT IS IMPORTANT

More information

Coverage Section(s) Requested

Coverage Section(s) Requested i ll Proposal Form Management Liability Insurance CLAIMS MADE WARNING FOR APPLICATION: This Proposal Form is for a Claims Made and Reported Policy, relating to claims made against the Insureds during the

More information

Specified Professions Professional Liability Product

Specified Professions Professional Liability Product Specified Professions Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy carefully. SECTION I: BACKGROUND

More information

Property Managers Professional Package Product

Property Managers Professional Package Product COMMITTED TO A MAKING DIFFERENCE Property Managers Professional Package Product PROPERTY MANAGERS PROFESSIONAL PACKAGE PRODUCT APPLICATION All questions must be answered and application must be signed

More information

DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION

DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO ITS TERMS. THIS POLICY APPLIES

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO

More information

Philadelphia Insurance Companies One Bala Plaza, Bala Cynwyd, Pennsylvania 19004 1.800.873.4552 Fax: 610.617.7940

Philadelphia Insurance Companies One Bala Plaza, Bala Cynwyd, Pennsylvania 19004 1.800.873.4552 Fax: 610.617.7940 Philadelphia Insurance Companies One Bala Plaza, Bala Cynwyd, Pennsylvania 19004 1.800.873.4552 Fax: 610.617.7940 PROFESSIONAL LIABILITY FOR SPECIFIED PROFESSIONS APPLICATION FOR CLAIMS-MADE INSURANCE

More information

1. a) Name of Applicant: (Whenever used in this Application, the term "Applicant" shall mean the Parent Corporation and all Subsidiaries.

1. a) Name of Applicant: (Whenever used in this Application, the term Applicant shall mean the Parent Corporation and all Subsidiaries. Executive Risk Indemnity Inc. Home Office Wilmington, Delaware 19805-1297 Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR DIVERSIFIED HEALTHCARE

More information

Title Agents Professional Liability Application

Title Agents Professional Liability Application 1. Name of Applicant Address Phone Number Fax Number E-mail Address 2. Are there other office locations? Yes No If yes, please list (include county): 3. Applicant is: Sole Proprietor Partnership Corporation

More information

Member Companies of American International Group, Inc. AIG MuniPro PUBLIC OFFICIALS AND EMPLOYMENT PRACTICES APPLICATION

Member Companies of American International Group, Inc. AIG MuniPro PUBLIC OFFICIALS AND EMPLOYMENT PRACTICES APPLICATION Member Companies of American International Group, Inc. AIG MuniPro PUBLIC OFFICIALS AND EMPLOYMENT PRACTICES APPLICATION Name of Insurance Company To Which Application is Made Name of Insurance Company

More information

EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION

EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION 595 STEWART AVE GARDEN CITY, NEW YORK 11530-4735 P 516-745-1111 F 516-745-5733 SOBELINS.COM EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS SUBMITTED

More information

New Business Application. Real Estate Professional Liability (E&O) Insurance

New Business Application. Real Estate Professional Liability (E&O) Insurance New Business Application The Hanover Insurance Company 440 Lincoln Street, Worcester, MA 01653 Citizens Insurance Company of America 645 West Grand River Avenue, Howell, MI 48843 Please submit application

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability COMMITTED TO A MAKING DIFFERENCE Personal Lines Insurance Agents Professional Liability INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION All questions must be answered and application must

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability Personal Lines Insurance Agents Professional Liability PART I - AGENCY DETAILS P.O. Box 2909 Jacksonville, FL 32203-2909 Phone: 800-342-2498 Fax: 904-355-7611 www.shellyins.com INSURANCE AGENTS AND BROKERS

More information

Specified Professions Professional Liability Product

Specified Professions Professional Liability Product COMMITTED TO A MAKING DIFFERENCE Specified Professions Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy

More information

UNDERWRITTEN IN FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY A. GENERAL INFORMATION

UNDERWRITTEN IN FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY A. GENERAL INFORMATION Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey 07059 APPLICATION VENTURE CAPITAL ASSET PROTECTION POLICY UNDERWRITTEN IN FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY

More information

ACE American Insurance Company

ACE American Insurance Company Named Applicant: Date: ACE American Insurance Company ACE Advantage ACE American Insurance Company National Association of REALTORS Professional Liability Name of insurance company to which Application

More information

REAL ESTATE RELATED ERRORS & OMISSIONS APPLICATION

REAL ESTATE RELATED ERRORS & OMISSIONS APPLICATION Kinsale Insurance Company P. O. Box 17008 Richmond, VA 23226 (804) 289-1300 www.kinsaleins.com REAL ESTATE RELATED ERRORS & OMISSIONS APPLICATION APPLICANT S INFORMATION 1. Legal name of the business who

More information

INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES

INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES NOTICE: INSURING AGREEMENTS I.A., I.C. AND I.D. OF THIS POLICY PROVIDE COVERAGE ON A CLAIMS MADE AND REPORTED BASIS AND APPLY ONLY

More information

BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH THE INSURANCE COMPANY INDICATED ABOVE (THE INSURER ).

BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH THE INSURANCE COMPANY INDICATED ABOVE (THE INSURER ). Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company FOR PROFIT MANAGEMENT

More information

THE HARTFORD PROFESSIONAL CHOICE LIABILITY POLICY INSURANCE APPLICATION

THE HARTFORD PROFESSIONAL CHOICE LIABILITY POLICY INSURANCE APPLICATION Name of Insurance Company to which Application is made THE HARTFORD PROFESSIONAL CHOICE LIABILITY POLICY INSURANCE APPLICATION This is an application for a CLAIMS-MADE AND REPORTED Policy If a policy is

More information

MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE

MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE POLICY Underwriting and Claims Manager: Media/Professional Insurance M1 053 (10-06) Page 1

More information

National Union Fire Insurance Company of Pittsburgh, Pa. LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION

National Union Fire Insurance Company of Pittsburgh, Pa. LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION National Union Fire Insurance Company of Pittsburgh, Pa. (herein called the Insurer ) LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION NOTICE THIS IS AN APPLICATION FOR INSURANCE WRITTEN ON A CLAIMS

More information

6. Number of employees including principals: Full-time Part-time Seasonal Total

6. Number of employees including principals: Full-time Part-time Seasonal Total Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED

More information

Credit Insurance Application

Credit Insurance Application Credit Insurance Application 1. General Information Name of Applicant Address City State Zip Phone Fax Email Representative and title of person designated to receive all notices concerning this insurance:

More information

Most Recent FYE (Month/Year) ( / ) Current Assets $ $ Total Assets $ $

Most Recent FYE (Month/Year) ( / ) Current Assets $ $ Total Assets $ $ Travelers Excess and Surplus Lines Company Wrap Employment Practices Liability Renewal Coverage Application The term Applicant means all corporations, organizations or other entities, including subsidiaries,

More information

6. Number of employees including principals: Full-time Part-time Seasonal Total

6. Number of employees including principals: Full-time Part-time Seasonal Total Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED

More information

ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION THIRD PARTY ADMINISTRATORS/BENEFIT ADMINISTRATORS ERRORS AND OMISSIONS

ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION THIRD PARTY ADMINISTRATORS/BENEFIT ADMINISTRATORS ERRORS AND OMISSIONS ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION THIRD PARTY ADMINISTRATORS/BENEFIT ADMINISTRATORS ERRORS AND OMISSIONS 1. Name and Address of Applicant: (Please include DBA s/subsidiaries, etc.)

More information

APPLICATION FOR TITLE AGENTS, ABSTRACTORS, AND ESCROW AGENTS ERRORS AND OMISSIONS LIABILITY INSURANCE

APPLICATION FOR TITLE AGENTS, ABSTRACTORS, AND ESCROW AGENTS ERRORS AND OMISSIONS LIABILITY INSURANCE APPLICATION FOR TITLE AGENTS, ABSTRACTORS, AND ESCROW AGENTS ERRORS AND OMISSIONS LIABILITY INSURANCE Please complete this application in ink and answer all questions. An incomplete application cannot

More information

Name of Insurance Company to which Application is made THE HARTFORD CYBERCHOICE 1.0 LIABILITY POLICY INSURANCE APPLICATION

Name of Insurance Company to which Application is made THE HARTFORD CYBERCHOICE 1.0 LIABILITY POLICY INSURANCE APPLICATION Name of Insurance Company to which Application is made THE HARTFORD CYBERCHOICE 1.0 LIABILITY POLICY INSURANCE APPLICATION This is an application for a CLAIMSMADE AND REPORTED Policy If a policy is issued,

More information

ACE DigiTech SM Digital Technology & Professional Liability Small Business Application

ACE DigiTech SM Digital Technology & Professional Liability Small Business Application Westchester Fire Insurance Company ACE DigiTech SM Digital Technology & Professional Liability Small Business Application NOTICE The Policy for which you are applying is written on a claims-made and reported

More information

Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION

Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION SM Travelers Casualty and Surety Company of America Hartford, Connecticut Important Note: This is an

More information

AIG CORPORATE IDENTITY PROTECTION

AIG CORPORATE IDENTITY PROTECTION Name of Insurance Company To Which Application is Made Name of Insurance Company to which Application is made (herein called the Insurer ) AIG CORPORATE IDENTITY PROTECTION NOTICE: AMOUNTS INCURRED FOR

More information

Application EXECUTIVE LIABILITY AND ORGANIZATION REINBURSEMENT INSURANCE

Application EXECUTIVE LIABILITY AND ORGANIZATION REINBURSEMENT INSURANCE Application EXECUTIVE LIABILITY AND ORGANIZATION REINBURSEMENT INSURANCE FL- 024 DOFIRST NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED

More information